Some families sometimes wonder if their loved one died because
of the terminal illness or if the cause of death was related to
the use of medications given during hospice care. Normally, most
patients die due to their terminal illness and the medications
given are simply to control pain or other distressing symptoms.
It is important for families to ask questions and get answers
from hospice staff so that all the family members understand the
reason for the various medications used.

Communicating with other family members who have questions is
important as well, because some family members may not have been
present when explanations about medications were given by hospice
staff. Sharing this information can reduce stress and worry in
other family members. Hospice staff need to be alert to detect
these sometimes unspoken questions in family members and to
provide explanations about the medications and treatments given
during hospice care.

Assisted Suicide, Death and Murder

In very rare circumstances which have been documented and
confirmed by the courts, some physicians and/or hospice staff
have given medications in dosages which were either inappropriate
or given in larger dosages than that needed by the patient,
resulting in adverse reactions and in some cases, even death.
Accidental administration of an overdose of any medication is one
thing, but intentionally overdosing a patient is in a very
different category of action. Intentionally overdosing a patient
so as to cause death may be termed "active euthanasia."
and if involuntary, "plain talk" would call it murder.

Blatant violations of the standards of care occur when a patient
is given a medication that he or she is allergic to and which he
directly refuses. A patient always has the right to refuse a
medication, even if the medication is appropriate. Some state
regulations govening hospice specifically mandate that a hospice
patient has the right to refuse a medication or treatment without
risking being discharged from the hospice. A basic principle of
health care is "informed consent." Consent of a patient
means that the patient accepts the procedure, medication or
treatment plan. If a patient does not consent, then a physician
or nurse cannot continue to impose a procedure, medication or
treatment against the patient's will.

Assisted Suicide is Not Accepted in Hospice Regulations

Dr. Jack Kevorkian brought the idea of assisted suicide to the
forefront of public debate in the late 1990s and the public
rejected his views. However, a small portion of the public still
favors the use of assisted suicide. In some cases, health care
workers have unilaterally decided to administer "assisted
suicide" to willing or unwilling victims of their philosophy
of hastening death. An unwilling suicide is not suicide but
rather is labeled murder by the courts. Administering potassium
chloride as an agent for causing death was one method popularized
by Dr. Jack Kevorkian (who was found guilty of violating the law
and is now residing in jail).

It is not necessary however, for an overly eager proponent of
assisted suicide to use an agent as deadly as potassium chloride.
These misguided individuals believe it is their role to hasten
death as an act of mercy, similar to how dogs and cats may be
"put to sleep" when they become too ill. In our
society, putting a person "to sleep"/to death
intentionally is labeled murder and is a criminal offense. Even
in a location where "assisted suicide" is legalized,
administering an agent that causes death to an unwilling
terminally ill patient is still considered murder.

Just because a patient has a terminal illness does not lessen
the value of that person's life. A patient may be elderly,
sick and weakened. However, noone knows with certainty exactly
when a terminally ill patient would die. Some patients die within
days, others within weeks and some within months or even years.
Cases of seemingly miraculous recoveries have been documented.
Hospice regulations do not normally allow for the performance of
assisted suicide in a hospice program. Performing assisted
suicide is illegal in all states except for Oregon. Any
individual who informs you that a hospice has a right to perform
assisted suicide is misinformed.

Overmedicating the Terminally Ill:
A Method of So-Called "Mercy Killing" or
Euthanasia

One method of hastening death used by physicians, nurses and
even family members is to administer overly high dosages of
narcotics, sedatives or antidepressants when the patient has no
need for them. Giving high dosages of narcotics when the patient
is not in pain or does not have a symptom requiring the use of
that narcotic is inappropriate and may cause death. The most
serious adverse effect of giving inappropriately high doses of
narcotics, sedatives and antidepressants is "respiratory
depression." Respiratory depression can be so severe that
breathing stops altogether resulting in death. Families need to
ask questions and know exactly why medications are given and to
be especially aware of rationales for increasing a dose.

Morphine is commonly given for severe pain in terminal
illnesses, especially in cancer pain. In the case of severe pain,
extremely high doses of morphine or other narcotics may be
necessary to control that pain and have been determined to be
safe to administer under the careful supervision of the physician
and hospice staff. Morphine is also given for other reasons which
most family members may not understand. For example, in the case
of end-stage heart failure with respiratory congestion resulting
from the weakened heart action, fluid from the blood percolates
out through the capillaries in the lung, causing severe
respiratory congestion and distress. Medical textbooks list
morphine given in combination with a diuretic like Lasix
(furosemide) as a classic and one of the most effective ways of
reducing respiratory distress and congestion caused by such heart
failure.

In the case of overly high dosages of narcotics, sedatives and
antidepressants, family members may be the only protection left
for a medically comatose patient. "Medically comatose"
refers to a patient that would not normally be comatose at that
time due to his illness, but who has been placed into a coma
(nonresponsive and unarouseable mode) by medications being given.
The patient can no longer speak for himself, and the family is
the only advocate left for that patient. If the patient was
willing to sleep during the very last days of his life, then
administering high doses of sedatives might be acceptable if the
situation warranted it. However, there are physicians and nurses
who believe in administering high doses even when the patient is
not willing and receptive to those doses.

Research Demonstrates Some Physicians
Approve of Actively Causing Death (Active Euthanasia)

Research studies published in medical journals confirm that a
small percentage of health care professionals, including
physicians, admit to having hastened a patient's death. It is
reasonable to conclude that a larger number have hastened death
and that some physicians are not willing to admit what they
routinely do in secret. The ethics of physician assisted suicide
is currently being actively debated throughout our nation.

A 1998 article in the Journal of the American Medical
Association conclusively reports that physician assisted suicide
or hastening death is occurring and is not "unheard of"
or a "rare" occasion. This report documents cases where
the patient wished to die and was assisted by his or her
physician to do so. A summary of this article is listed at: The practice of euthanasia and physician-assisted
suicide in the United States. [For complete article see JAMA 1998 and
search from the JAMA site for the following article: Aug
12;280(6):507-13 entitled "The practice of euthanasia and
physician-assisted suicide in the United States: adherence to
proposed safeguards and effects on physicians." written by
Emanuel EJ, Daniels ER, Fairclough DL, Clarridge BR done at the
Center for Outcomes and Policy Research, Division of Cancer
Epidemiology and Control, Dana-Farber Cancer Institute, Boston,
Mass 02115, USA.]

In the above survey of 355 oncologists, "(15.8%) reported
participating in euthanasia or physician assisted suicide."
"Thirty-eight of 53 oncologists described clearly defined
cases of euthanasia or physician assisted suicide." In the
cases reported by that 15.8% of oncologists, "(60.5%) [of
the patients] both initiated and repeated their request for
euthanasia or physician assisted suicide, but 6 patients
(15.8%) did not participate in the decision for euthanasia or
physician assisted suicide. [emphasis added]
Thirty-seven patients (97.4%) were experiencing unremitting pain
or such poor physical functioning they could not perform
self-care."

What does it mean that "6 patients did not participate in
the decision for euthanasia or physician assisted suicide?"
Isn't the obvious conclusion: these patients died
without having requested to be killed, without asking for their
death to be hastened. Who is deciding who dies and who lives in
these situations? Do doctors have the right to play God with the
terminally ill, even when the patients have NOT requested such
"assistance?"

In the case of a patient who definitely does not wish to
die and who is actively "euthanized" against his
wishes, that is an even more serious question of medical ethics
and law. If you are aware of a situation where the physician,
nurse or other family member is giving dosages of medication
which have been directly refused by your loved one, you need to
directly confront that physician, nurse or family member and ask
them to explain their actions. If you are not satisfied with that
explanation, you need to promptly get in touch with an attorney
for professional advice.

American Nurses Association
Stands Against Active Euthanasia"

The American Nurses Association, the major professional
nursing association in the United States has stated:

"The American Nurses Association (ANA) believes that the
nurse should not participate in active euthanasia because such an
act is in direct violation of the Code for Nurses with
Interpretive Statements (Code for Nurses), the ethical traditions
and goals of the profession, and its covenant with society.
Nurses have an obligation to provide timely, humane,
comprehensive and compassionate end-of-life care." See the
American Nurses Association website.

American Medical Association
Opposes Physician Assisted Suicide

The American Medical Association, one of the largest physician
organizations in our nation has taken the following official
position on physician assisted suicide:

"...the American Medical Association strongly oppose[s]
any bill to legalize physician-assisted suicide or
physician-assisted death because physician-assisted suicide is
fundamentally inconsistent with the physician’s role as a
healer."

Significant Number of Physicians May Approve of Euthanasia
and/or Physician Assisted Suicide

It is common knowledge in hospice that there are some
physicians in the community who do not prescribe adequate pain
medications to properly control the pain of patients with severe
pain. It is also common knowledge in the industry that there are
some physicians who are extremely "aggressive" in
treating pain with narcotics. Being "aggressive" in
treating pain is admirable and exactly on target when it comes to
hospice care and its reason for being. However, it is also common
knowledge that some physicians step over the line and are willing
to "push" a patient into death by hastening its arrival
through the use of high doses of sedatives and narcotics.
Hospices will not normally inform you or your loved one if your
physician falls into either extreme category: those who
under-medicate for pain or those who overmedicate and hasten
death.

An article in the Archives of Internal Medicine, Vol. 160 No. 1,
January 10, 2000, "Attitudes and Practices Concerning the
End of Life - A Comparison Between Physicians From the United
States and From the Netherlands" (by Dick L. Willems, MD,
PhD; Elisabeth R. Daniels; Gerrit van der Wal, PhD; Paul J. van
der Maas, PhD; Ezekiel J. Emanuel, PhD) reports the varying
percentages of physicians in Oregon who were willing to increase
the dosage of morphine given under various patient circumstances.
This article is summarized briefly at: Entrey-PUBMED where you can search for the
article by title, you can also order a full copy of the article.
The article is also available from the AMA site at: Archives of Internal Medicine - AMA

When pain was involved, 97% stated they approved of increasing
the dosage of morphine; 53% approved of physician assisted
suicide ("PAS") 24% approved of euthanasia

When severe weakness and debility of the patient were
involved, 36% approved of increasing the dosage of morphine; 37%
approved of "PAS"; and 14% approved of euthanasia.

When patients felt that they were a burden on their families,
24% of the physicians approved of increasing the morphine dosage;
24% approved "PAS"; 7% approved of euthanasia.

When patients felt that their lives were meaningless, 20% of
the physicians approved of increasing the morphine dosage, 22%
approved of "PAS", and 7% approved of euthanasia.
See the table of data at:
http://archinte.ama-assn.org/issues/v160n1/fig_tab/ioi81180_t3.html

Increasing the dosage of morphine when pain is involved makes
sense and leads to improved quality of life for the terminally
ill. However, other than hastening a patient's death, what is
the reasoning for increasing the dosage of morphine when patients
feel their life is meaningless or feel that they are a burden on
others in the family? It is obvious that physicians approve of
hastening death in many end of life circumstances. 20% or one out
of five physicians approved of "PAS" when patients felt
their lives were meaningless. 24% approved of PAS when the
patient felt they were a burden.

Even more surprising is that 24% of the physicians approved of
euthanasia when the patient had severe pain, 14% (or one out of
every 7 physicians) approved of PAS when the patient had
debility, 7% when the patient felt they were a burden or felt
that their lives were meaningless. 7% is one out of 14 physicians
who admitted to being willing to act to end a patient's life
in those circumstances.

48% of the physicians reported that patients had requested
"PAS" or euthanasia. None of the physicians admitted to
having performed euthanasia, but 7% admitted to performing
"PAS", and 2% admitted to ending a patient's life
without a request from the patient.

While these results are from confidential surveys of physicians
in Oregon, attitudes of physicians around the country may be
quite similar.

Durable Power of Attorney for Medical Care Does Not Give
Right to Overmedicate and Kill a Patient

Some family members who have been approved and appointed by
the terminally ill patient as their Representative for medical
decisions feel that they have the right to "do
anything." However, the regulations regarding the
administration of medications do not allow medications to be
given in a manner contrary to the physician's orders. Nor
does a medical power of attorney allow the Representative to
intentionally go against the conscious wishes of the terminally
ill patient. Even if morphine or other narcotics are ordered to
be given for pain, that does not mean that the family member can
give whatever dose they want to give. If death results when a
family member gives an overdosage of narcotic, the family member
may be held responsible for that death, rather than the
physician.

Even if the killing is done out of a belief in euthanasia or
mercy killing, it is still killing or causing death. The district
attorney or U.S. attorney for that region would be able to bring
a charge against the individual involved and the criminal court
system would then be able to rule on what punishment would be
appropriate for a person who is found to have intentionally
caused another person to die, even in the case of a terminally
ill patient.

If a patient or loved one had refused certain medications and
those medications were given against his or her will, and the
patient later died when those medications were given, you need to
consult an attorney who has expertise in criminal law. By
discussing the situation with an attorney with expertise in
criminal law, the attorney will be able to advise you how to
proceed to address your concerns. In some cases, family members
have actually gone to the County District Attorney or U.S.
attorney and had charges brought against unethical health care
staff who have intentionally killed a patient.

Criminal Prosecutions on Record for Hastening Death

For a discussion of the criminal prosecutions of some cases
involving the deaths of patients in health care situations,
please refer to the following article posted at the American
Society of Law, Medicine and Ethics website: "Criminal Act or Palliative Care? Prosecutions
Involving the Care of the Dying" by Ann Alpers, JD. Ann
Alpers is a professor at the University of California at San
Francisco's School of Medicine and has taught Medical
Bioethics, among other topics.

What To Do About Involuntary Euthanasia

If you know of any incidences of involuntary euthanasia where
a patient was medically killed (various methods), please contact
us to let us know. Visit our euthanasia and hospice information center where we
provide directions on how to stop these medical killings.
Involuntary euthanasias, if continued, offer the greatest threat
to hospice as we know it. In countries where euthanasia is
encouraged, hospice services decline and patients are killed
rather than cared for (documented in The Netherlands, Europe).

One important point to remember though, you will need to send
a detailed complaint to the State Board of Medicine as soon as possible,
because in some cases, the DEA will wait to see the findings of
the State Board of Medicine. You can also file a complaint to the
State Board of
Nursing if a nurse was involved in administering a fatal dose
of narcotic. It is wise to consult a medical malpractice attorney
before filing your complaint to the Board of Medicine and it is
also important to get a medical review by an independent physician.

If you wish to stop the involuntary euthanasias (medical
killings of patients), you will need to get a copy of the medical
record for an independent medical review of your loved one's
case. Your attorney can assist you in that, because most hospices
will fight tooth and nail to never give you the medical records
if something truly terrible happened. If you don't have or
know of a medical malpractice attorney in your area, you can search for a
plaintiffs' attorney.

It is very important that you try to find an attorney who
files claims as a plaintiffs' attorney to represent you. If
you get an attorney who handles medical malpractice, but
regularly represents the corporations, you may not get the legal
representative you deserve! Hospices have been known to falsify
documentation, delete information, send incomplete records, stall
and many other tactics that infuriate the families of the
victims. A plaintiff's attorney will be able to successfully
overcome the obstacles that hospice corporations routinely throw
in the way of families seeking the truth (and a full, accurate
copy of the medical record).

Taking the step by step approach to achieving justice will
help make it more likely that the truly egregious violations of
standards of care are noted (some you may miss, not being a
physician) and corrected through the government justice
departments and local district attorney's office. Having a
medical malpractice attorney help you will assure that the
complaint to the Board of Medicine and Board of Nursing is
written in such a way that the allegations are not capable of
being misunderstood or brushed aside.

If people remain silent about these medical killings, nothing
will happen. Rape, murder and child molestation can only flourish
if families or victims remain silent. Only when crimes are
reported can they be stopped. In the same way, hospice abuses
must be reported for the medical killings (involuntary
euthanasias) to stop. We urge you to report what you know to our
government representatives. See our hospice and euthanasia
information and action center for addresses to write to, sample
letter and examples of involuntary euthanasias in our nation. You
can make a difference! Let others know about our efforts to stop
medical killings!

The Hospice Patients Alliance provides information in the
spirit of consumer advocacy, believing that informed consumers of
healthcare are best able to protect their rights and obtain
quality hospice care. If you have questions about the legality of
certain health care interventions and are seeking legal or
medical advice, we strongly encourage you to consult with a
competent and experienced attorney or physician. In order to
obtain completely objective and un-"politicized"
advice, you may need to consult with an attorney or physician who
is not located in the same area as the hospice or physician
involved.

Read
The Heart Of End-Of-Life Care, an E-book containing essays which reveal the mission of hospice and end-of-life care.
Learn about the dangers threatening the industry and the public in the 21st century.
This E-book is available by download online.